What does the ACR/EULAR RA mitigation standard update optimize? Research Express

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At present, the primary goal of RA treatment is clinical remission, and low disease activity can be selected as an alternative treatment target
for patients with a long course of disease.
Current criteria for assessing remission status are diverse and include criteria based on 28 joint disease activity scores (DAS28<2.
6), clinical disease activity index (CDAI≤2.
8), simplified disease activity index (SDAI≤3.
3), and Boolean mitigation criteria<b11>.
In 2010, ACR/EULAR proposed the Boolean remission criteria for RA, that is, when the patient meets 1 TJC≤, 1 SJC≤, CRP ≤1mg/dl, PGA ≤ 1 point (0~10 points), it is defined as clinical remission
.

In the latest Code of Practice for the Diagnosis and Treatment of Rheumatoid Arthritis, SDAI and CDAI are recommended to assess the disease activity of RA, and Boolean criteria
can also be used when aiming for clinical remission.
Based on recent findings, a higher patient's overall disease score (PGA) threshold may improve the consistency
of Boolean and index scoring systems.

Brief introduction to the study

In this context, Studenic, a scholar at Karolinska Institutet, a renowned Swedish medical school, and his collaborators used higher PGA thresholds to verify the consistency of the revised Boolean mitigation standard with
other mitigation criteria.
The study was published Oct.
24 in the journal Ann Rheum Dis.
(impact factor 27.
973).

Using data from four randomised trials comparing biologics to improve the condition of antirheumatic drugs versus methotrexate or placebo, the recommended higher PGA threshold of 2 cm (Boolean 2.
0) (range 0-10 cm) compared to the original threshold of 1 cm (Boolean 1.
0)
was used.
The agreement of mitigation criteria based on Boolean and exponential (SDAI, CDAI) was analysed, and the predictive effect of each definition of mitigation on subsequent physical functioning (Health Assessment Questionnaire [HAQ] score ≤0.
5) and radiographic progression was examined
.

➤Boolean 2.
0 is more consistent with SDAI or CDAI mitigation standards

Among the 2048 trial participants included in the study (1101 with early RA and 947 with confirmed RA), after six months of treatment, the response rate using Boolean 2.
0 criteria was higher compared with Boolean 1.
0: early RA (14.
8% vs.
20.
6%); Confirmed RA (4.
2% vs.
6.
0%)
.
Boolean 2.
0 is better aligned with SDAI or CDAI mitigation standards than Boolean 1.
0, especially in early RAs (Figure 1).

Figure 1 Response rate under each standard

➤The predictive value of Boolean 2.
0 on radiographic progress and functional outcomes remained

The study analyzed the proportion of patients classified according to different Boolean definitions at 6 months who achieved a good functional prognosis (HAQ score ≤0.
5) and radiological progression (ΔmTSS) within 1 year, and found that Boolean 2.
0, SDAI and CDAI mitigation criteria had similar positive likelihood ratios (LRs)
in predicting imaging progression and good functional prognosis.

The data showed that more patients achieved remission based on the Boolean 2.
0 criteria and increased consistency with SDAI and CDAI index response criteria without diminishing the predictive value
of patient radiographic progress and functional outcomes.
Therefore, the study supports the widespread application of
the Boolean 2.
0 mitigation standard.

conclusion

Remission has become a key goal
in the management of patients with RA.
The 2011 ACR/EULAR initiative on mitigation criteria aims to harmonize the definition of the term "mitigation" to facilitate the cross-cutting assessment and comparison of response rates in clinical trials and clinical practice, and to reduce heterogeneity
.
This study validates that the performance results of the Boolean 2.
0 criterion are consistent
with the accepted exponential-based definition of mitigation.
With the validation of the PGA2cm threshold, it is recommended that this revised ACR/EULAR mitigation criterion be adopted in future clinical trials as a therapeutic goal
in clinical practice.

References: Studenic P, Aletaha D, de Wit M, et al.
American College of Rheumatology/EULAR remission criteria for rheumatoid arthritis: 2022 revision.
Ann Rheum Dis.
2022 Oct 24:ard-2022-223413.
doi: 10.
1136/ard-2022-223413.
Epub ahead of print.
PMID: 36280238.